This application is for screening purposes only. Please enter your information and
send it along with a copy of your completed Release and Waiver Form to:

Plenty International
PO Box 394
Summertown, TN 38483

Date: __________________________________________

Contact information:

Name:_________________________________________________________________________

Address:_______________________________________________________________________

City: ____________________________________ State: ______________ Zip: _____________

Phone: ___________________________________ Fax: ________________________________

E-mail:__________________________________________

Please list two references and contact numbers:______________________________________

______________________________________________________________________________

______________________________________________________________________________


General Information:

Dates you are available to volunteer: ______________________________________________

Plenty Programs of interest:_______________________________________________________

Special skills you are able to utilize, share and/or teach (ie: photography,

writing, language, construction, etc):_______________________________________________

______________________________________________________________________________

Your educational background (ie: degrees, certificates, special training received):

_____________________________________________________________________________

_____________________________________________________________________________

Previous teaching or training experience, if any:______________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Previous international travel, volunteer or work experience and dates:__________________

_____________________________________________________________________________

_____________________________________________________________________________

Languages spoken (indicate whether you are fluent, conversational, or beginner level):

_____________________________________________________________________________

Have you ever been convicted of any crime? Please explain:__________________________

_____________________________________________________________________________

Are you able to pay for your round trip travel costs to the project site and living expenses
while volunteering? (Cost of airfare, housing, food canvary greatly depending upon the
project site – consider an average of $500 for travel and$500/mo for living expenses)

_____________________________________________________________________________

Reasons for wanting to volunteer: _______________________________________________

How did you hear about Plenty? _________________________________________________

______________________________________________________________________________


Medical:

What is your overall level of physical fitness? (ie: excellent, good, fair, poor):

____________________________________________________________________________

Do you have any physical conditions that might affect your ability to volunteer?

If so, please explain:___________________________________________________________

____________________________________________________________________________

Some project sites may expose you to mold. Do you have asthma, arespiratory condition,

or allergy to mold?_____________________________


EMERGENCY CONTACT INFORMATION

Name of Volunteer:_____________________________________ Date:_________________


IN CASE OF EMERGENCY, PLEASE CONTACT:

Name:________________________________________ Relationship:___________________

Address:____________________________________________________________________

City:____________________________ State:________________ Country:______________

Day Phone:__________________________ Night phone:____________________________


The following information may be needed by medical personnel:

Allergies to medicine, food, etc:_________________________________________________

Are you taking any medications? If so, which______________________________________

___________________________________________________________________________

Physical conditions such as chronic illnesses:______________________________________

Date of last tetanus shot:______________________________________________________

Other information:____________________________________________________________


Personal Physician:

Name:______________________________________________________________________

Address:____________________________________________________________________

City:___________________________ State:__________________ Country:_____________

Day Phone:____________________________ Night phone:___________________________


Personal Health Insurance Coverage:

Company:_________________________________ Policy Number:_____________________

Phone number:_______________________________________________________________

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